SCAI releases recommendations for renal artery stenting
Experts from the Society for Cardiovascular Angiography and Interventions (SCAI) recommended the use of renal artery stenting to benefit patients who historically were excluded from clinical trials in a document published Aug. 19 in Catheterization and Cardiovascular Intervention.
Following the outcome of several recent trials, SCAI determined that a document was needed to outline when renal artery stenting was most and least appropriate based on the evidence.
“The CORAL [Cardiovascular Outcomes in Renal Atherosclerotic Lesions] trial answered many of our questions about renal artery stenting, but some patients who are seeking treatment today were not included in CORAL, including patients in whom optimal medical therapy failed," said first author Sahil A. Parikh, MD, of Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine in Cleveland in a press release. "The new recommendations were developed to help physicians evaluate treatment options for the broad range of patients with renal artery disease."
Parikh and colleagues warned that renal artery stenosis, while asymptomatic, can lead to kidney or heart failure, particularly when high blood pressure goes unchecked. Renal artery stenting could provide relief when optimal medical therapy fails.
The guidelines stated that in agreement with multisocietal guidelines for Class I recommendations, for patients with “flash” pulmonary edema or cardiac disturbance syndrome stenting represents appropriate care. This also is considered appropriate for patients whose kidney function is in jeopardy and whose high blood pressure can be traced to decreased function in both or the sole remaining kidney.
They noted a series of conditions where renal stenting may be appropriate but have not been fully supported through current research. Those include higher-risk patients with global renal ischemia and estimated glomerular filtration rat (eGFR) of less than 45 cc per minute, and some patients with hemodynamically significant unilateral renal artery stenosis with congestive heart failure. Patients with challenging or high-risk lesions, Parikh et al wrote, should have risks weighed against benefits, including operator skill to determine appropriateness for the individual patient.
Parikh et al wrote that stenting was rarely appropriate when stenosis was middle to moderate. Further, patients should be fully tested to assess the stenosis, risks and benefits before a stent is placed.
Included in the recommendations of the expert panel was advice to minimize invasive testing and exercise caution when using computerized tomographic angiography (CTA) or magnetic resonance arteriography (MRA) with patients experiencing severe renal dysfunction. The recommended tool was renal artery duplex ultrasonography (RADIUS), which they stated was sensitive, specific, inexpensive and repeatable with minimal risk to the patient.
Other suggestions for safe and accurate scanning of renal artery stenosis encouraged minimal use of contrast and a strong recommendation of digital subtraction angiography, as well as selective renal angiography where the entire kidney is visualized to ensure perfusion and rule out infarction, cysts or renal masses.
Parikh et al emphasized that further research was needed to explore best practices for renal stenting and to further clarify appropriateness categories.
"As our understanding of PAD [peripheral artery disease] and its treatment options grows, physicians have the ability to improve symptoms and quality of life for many more patients today," said SCAI 2014-15 President Charles Chambers, MD, of the Cardiac Catheterization Laboratory at Penn State Hershey Medical Center in Hershey, Penn. in the press release. "Our series of treatment recommendations is designed to help interventional cardiologists provide the best possible care based on each patient's individual symptoms and condition."